Neonatal Jaundice

I recently transferred to the Maternal Child Care (Postpartum) Unit at my work and as kind of a homework assignment I'm exploring the pathology of a common complication for newborns: Jaundice.

Mostly in the past when I've taken care of people with jaundice it's because they have really bad liver disease. So bad that their livers can't get rid of bilirubin, a waste product of erythrocytes (red blood cells). In babies, it usually works a little different. Their livers are immature, but aren't usually damaged as much as they are overloaded with more bilirubin than they can handle.

But first I'll explain the normal physiology of bilirubin production and elimination: Like a lot of the waste products in your body, bilirubin is transformed multiple times, and different molecules are added or subtracted so the waste product is 1) less toxic 2) easier for your body to identify and get rid of, because they can recognize that it's trash.

Most bilirubin comes from heme: a component of erythrocytes (or Red Blood Cells), where it exists as hemoglobin.

"Hemoglobin" is the part of the red blood cell that makes it red: it has the iron that holds on to the oxygen in your blood, and it's the thing that makes your blood red when it touches air; blue when it is oxygen deprived. It's a very important component of your blood, however erythrocytes, only live a short amount of time (120 days in adults, 70 days in fetuses) and they don't reproduce.

When they die, the body needs a way to get rid of the parts it doesn't need anymore. A lot of the bodies waste products are excreted by the kidneys, but heme is usually excreted from the liver into your intestines as a component of bile.


I'm gonna show you a picture just to give you an idea of how heme is transformed on it's way to leave your body:

^ When red blood cells die, they release the "heme" from the "globin" and the heme exists in a form called bilirubin.

It would be just sitting around in the blood, but luckily there's a really big, powerful protein (called Albuimin) already circulating in the blood that binds the bilirubin to itself and carries it where it needs to go. In this form, (attached to the Albumin) the bilirubin is called "Unconjugated". The unconjugated bilirubin travels to the liver where it is processed and sugars are attached to the Albumin-Bilirubin molecule. In this form, we call it "Conjugated" bilirubin, because of the way all those smaller molecules (sugar, protien, bili) are bonded together.

This form it should not be circulating in the blood, it should be excreted into the intestines, get broken apart by all the bacteria living there, and go out with all of your poop. But sometimes, if it sits in your intestines for too long (this happens when babies don't feed well) or you don't have enough intestinal flora growing in your gut (newborn babies have very little), it can be re-absorbed into the blood.

Your body, of course, tries to find other places to put it (it is a waste product after all, it's TOXIC!) and, a very small amount (1 percent) is converted to urobilinogen and excreted from the kidneys, but it's really not very much. So the conjugated bilirubin just kinda gets stuck in your body

E.V.E.R.Y.W.H.E.R.E.

It can get so bad, you can see it in your skin. It was red in your blood, but now it's YELLOW:


                                      

and your eyes!

 (This condition is called "Jaundice" or icterus)

But the WORST is when bilirubin gets to your brain, because it ends up causing encephalopathy and brain damage. (this is called Kernicterus)


Although Jaundice is relatively common in infants it's usually not a really big problem, most babies do have some degree of physiologic jaundice because their livers are immature. In a healthy infant who is feeding well usually won't need any treatment. Therefore, its important for parents to be able to distinguish when jaundice is progressing into a problem.


Jaundice can be particularly pathologic if it exhibits within the first 24 hours of an infants life. This is usually caused by an underlying condition that's contributed to the baby's red blood cells dying:

• Blood incompatability between the mother and the infant: Where the mother has produced coombs antibodies to the infant's blood.
• Infants with cephalohematoma, or bruising underneath their scalp (from a prolonged or traumatic birth)
• Infants who born earlier, who are small for gestational age, or twins, may have blood that's concentrated, and dies quicker
• Infection, or treatment with certain antibiotics.
• Respiratory distress/hypoxia
• Certain enzyme/metabolism disorders (Such as Gilbert's syndrome)
• Infants of asian parents (?? for some reason...their RBC's die quicker...idk...)

 If a baby has these risk factors, it's important to monitor for symptoms of jaundice and inform the baby's doctor. There are screening tools like the transcutanous bilirubinometer (TcB) that you can use to determine if the baby is at risk for developing jaundice:

The doctor may order labs for the baby: Total Serum Bilirubin (TBIL, or TSB), Conjugated Bilirubin (Direct bilirubin, or DBIL) or Unconjugated Bilirubin (Indirect, or IBIL...which they basically get just by subtracting: TBIL-DBIL=IBIL)

The doctor might also place the infant's discharge on hold to monitor make sure jaundice isn't progressing and that he or she is eating enough to expel all of that bilirubin from their gut.

Aside from yellowing of the skin, and mucous membranes and eyes, babies with jaundice are usually poor feeders (either they aren't interested in eating, they have a poor suck, or they aren't pooping and peeing appropriately/enough for their day of life). They're usually really tired and won't startle as easily, they'll wanna sleep though feedings.

At the later stages, the baby's body will tense up, they'll be irritable, and they'll have a high-pitched or shrill cry.

Fortunately, there are a lot of things we can do to treat jaundice.

If labs come back with high bilirubin levels, the doctor will probably order supplemental formula feedings and photo-therapy (blue or white light is preferred: 460-490)

via a lighted blanket that sticks to their back,



a bili-bed,



or a bili-lamp...which kinda looks like a little tanning bed for babies, they even wear these little eye protectors:




If the baby's condition is critical, the doctor might order an exchange transfusion (I'd imagine this only gets done in the Neonatal Intensive Care Unit), where they take out blood, and put in new blood until the baby's circulating blood supply is completely replenished. Apparently this is particularly effective if there are a lot of antibodies in the babies system from mom, against the babies blood (if anyone knows more about this, I'd love to hear your experiences. It sounds like a pretty interesting treatment...I imagine they use whole blood, not Packed RBCs)

If a baby is going home with jaundice, or even if the baby is at risk, it's important that the baby's parents know that they're infant is at risk and know what signs and symptoms to look for that their infant might be developing this condition. Some yellowing is to be expected, but yellowing of skin and eyes accompanied by poor feeding is a concern. It's important that they know who to contact if the problem worsens (the pediatrician, NOT the obstetrician). It's also important that they keep well-baby follow up appointments with the pediatrician to make sure their baby is adjusting well to extra-uterine life. 

Sometimes an infant with Jaundice will go home with a bili-blanket or bili-lights, sometimes the pediatrician will tell the parents to put the child in sunlight for a specific amount of time each day and to stimulate the baby to stay awake during feedings.




The risk for developing jaundice, and it's associated complications, is something we should assess in every baby. But it should not be something that causes a kid problems in the long run. Treatments for neonatal jaundice are very effective, as long as the symptoms are recognized and treated before it progresses to kernicterus. Doctors, nurses, and (most importantly) parents need to know what to look for in their infant, and when and how to seek help.



Sources:

http://www.vivo.colostate.edu/hbooks/pathphys/digestion/liver/neojaundice.html

http://medical-dictionary.thefreedictionary.com/bilirubin

https://labtestsonline.org/understanding/analytes/bilirubin/tab/test/

http://www.newkidscenter.com/How-to-Get-Rid-of-Jaundice-in-Newborns-at-Home.html

https://www.nlm.nih.gov/medlineplus/ency/article/007309.htm

http://www.lifewithkarma.com/2011/06/bili-baby.html

http://emedicine.medscape.com/article/1894477-overview

http://www.austincc.edu/emeyerth/hemoglob.htm

Book vs. Movie: 12 Years A Slave

I started reading this book on the airport to New York (OMW to watch Les Mis!)

Before I read this book or watched the movie, the most I knew about this story was the basic premise:

Based on a true story...A free man sold into slavery, won best picture in 2012...Benedict Cumberbatch plays one of the southern slaveowners etc...

So when I was in the airport reading the book, I was expecting a pretty straightforward account of Mr Solomon Northup's horrendous experiences in the south of the United States; possibly sprinkled about with anti-slavery propaganda appropriate for the time in which it was written and the indended audience would obviously be the people of the north. Basically I was expecting a heavy-handed expose on the atrocities of the south.

These expectations were seemingly reinforced when I read on the back cover that the narrative had been completed with the assistance of a ghost writer. So, I didn't go into this book expecting anything extraordinary as far as literary quality (although his experiences would certainly be worth reading about). 

Well, I won't say that parts of this book aren't heavy reading: it deals with some very heavy topics. The story is told in a a first person account, and it reads like something of a psychological thriller/horror story. But as far as literary quality I was completely mistaken; I don't think Solomon needed a ghostwriter to tell his story. The account was absolutely riveting and it was accompanied by an extremely thoughtful and on-point analysis of human nature in general. 

My favorite part is when Solomon talks about his "Master" Edwin Epps' eldest son:

"Young Master Epps possessed some noble qualities, yet no process of reasoning could lead him to comprehend, that in the eye of the Almighty there is no distinction of color. [...] Brought up with such ideas--in the notion that we stand without the pale of humanity--no wonder the oppressors of my people are a pitiless and unrelenting race."

This is an idea that's revisited several times in the story: 

• William Ford is a really decent guy, he cares about people, even slaves...even people who he considers to be inferior.
• Mrs Epps is pretty decent too, when she's not supper jealous of Patsy.
• Mr Epps...well he's actually a law-abiding man (ie...he's only as "bad" as the law will allow him to be.)
  

Solomon is not trying to paint the white people of the south as these atrocious monsters, these 'other' beings who need to be uprooted. He recognizes that these people see the world...not in the way it is...but the way they were taught that it is.

He's trying to understand them! And he's granting them a complexity of thought...a humanity...that he himself is denied. 

#ugh! #FEELS!

Another really interesting thing about this book is how he overcomes the whole slavery system they had set up in the south. I kept expecting him to run away and get rescued, which probably says something about the way I think about problems in general (the system as something that needs to be defied...) but we see numerous reasons in this book why that approach wouldn't work. Solomon repeatedly chooses to keep his head down, to work in this system rather than fight because he knows that people who run away don't get away. He knows he's not running from the masters but from a whole line of thought that's existed for a really long time and that permeates every aspect of their society. 

It's heartbreaking, gut-wrenching, thought provoking, riveting.  And the ending?! 

Definitely not a light read, but I highly recommend it if you want something that's exciting and thought provoking at once.

And now for the movie:

This is more going to be a "what the movie missed" section. For the most part, the movie is pretty loyal to the book. Solomon's home life being told in flashbacks and, of course, the book can give us an internal monologue that lest us get inside Solomon's mind in a way a movie can't but I was actually very surprised at how much they were able to fit into the film.

Here are the differences I noticed though:

• Solomon and Anne had three kids, not two. Their names were Elizabeth, Margaret, and Alonzo. (I think they took Elizabeth out because they already had another character with the name Eliza).
  

• Uncle Abram has significance in the story other than just dying. (In fact they kind of nerfed anyone who wasn't Patsy now that I think about it...)
  

• In the book, we don't really know if William Ford was turning a blind eye to the possiblity of Solomon being a free man. In the movie, Solomon actually tells him and he just goes: "La-la-la I can't hear you!" in the book, one of Solomon's regrets seems to be that he didn't tell him because he didn't know if he could trust Master Ford or not. (Remember, it's not these people who are his enemies: it's a whole system)
  

• They never show the Epps' children; the eldest son would have been around 12 or 13 at the end. So Solomon would have watched him grow from infancy.
  

• The guy who "rescued" Solomon wasn't just Parker the Random Store Clerk, his name was Henry Northup. (I think this was done to avoid explaining why there is a black and white family named Northup, although the explanation is actually quite simple.)
  

• In the book, Solomon never tells us anything explicitly sexual, however, it doesn't require a stretch of the imagination to realize the types of things depicted in the movie must have happened. It's there to show us how brutal this world is, there's nothing particularly seductive or explicit in it. 

• Solomon's reunion with his family is even more of a tear-jerker: Not only did his daughter name the first grandchild after him, Solomon's son Alonzo was away with the aim of making money to make a trip down to the south to find his father.
  

Overall I'd say that the movie is a loyal adaption to the book, the changes made were minimal and understandable. However, I should mention the movie is Rated R, there are strong thematic elements, intense situations as well as depictions of torture and rape. I would not recommend this for children, particularly if they haven't read the book.

The acting of the three main leads is fantastic, the story is powerful, but I don't see this movie as one for casual viewing. I watched it by myself, and it's not one I wouldn't feel comfortable watching in a group unless we were gonna talk about it afterwards.